Category Archives: Old people

In every population every individual is ageing. To say that we have an ageing population means that the average age of the population is rising or that the proportion of the population above a specified age is increasing.

This might be because people are living longer.

It might be because fewer people are dying young so that more people live to be old, but when they do become old they don’t live any longer than old people always have. Or it might be because the average age of death hasn’t changed but the number of young people being born or migrating in is not keeping pace with the number of people who are maturing into old age. This demographic ageing is nothing to do with changes in longevity but arises because of changes in birth rate or immigration now or in the past. This could arise either because of a fall in the birth rate or in immigration or because a large cohort of the population is coming into old age or into a more advanced stage of old age because of increases in birth rate 65-90 years ago.

DEMOGRAPHIC AGEING

Demographic ageing undoubtedly increases health and social care costs. Around the turn of the 19th/ 20th centuries there were sharp falls in infant mortality. Prior to that people had had large families but many of the children had died. Later on in the 20th century, when people realised their children were going to survive, they started to have smaller families. But for about a generation there were large families most of whom survived.

This began to cause demographic ageing as this generation reached old age in the last third of the 20th century. At first it affected a disproportionate number of women because a large proportion of the men had been killed in the First World War. Society was ill-prepared for it because the large number of single women created by the slaughter of men in the First World War had led to an expectation that there would always be a single daughter around to look after elderly parents but by the time this generation reached old age they had fewer children, fewer unmarried daughters, and fewer daughters who had not found another role in life as women were now educated and economically active.

Towards the end of the 20th century we began to see the coming into old age of the men who had been too young for the First World War and around the turn of the century the coming into old age of the first generation of men to have lived their entire adult lives in peacetime. This added to the demographic ageing but without the same gender gap.

Demographic ageing eased off in the first decade of the 21st century but in 2011 those conceived on VE night became 65. In 2016 they became 70. In 2036 they will become 90. This ageing of the post war baby boom is now the driver of demographic ageing. It is not as intense a process as the ageing that occurred at the end of the previous century.

There is however no doubt that demographic ageing increases health and social care costs by adding to the proportion of the population who are part of a group with higher than average need.

INCREASING LIFE EXPECTANCY

However demographic ageing is no longer the only factor in the ageing of the population. Life expectancy is also increasing.

That component of an ageing population which is due to increasing life expectancy does not necessarily increase health and social care need. A lot depends on how healthy we are in old age.

Let us assume that at the moment disability (and hence health care costs) occur as follows:-

care costs

The fear is that increasing life expectancy does not delay the onset of disability, it simply makes it last longer. For every extra year of life there is an extra life of woe. We live longer, but the extra time is spent taking longer to die.

more care costs later

In this case there will be a huge increase in disease burden for the individual (and hence health and social costs for the population) as a result of an increased life expectancy

Another possibility however is that all that happens is that disability and death are both delayed. For every extra year of life woe is delayed by a year but there is no change in the amount of woe. We live longer and the extra time is spent living – we spend no extra time on dying.

ageing population delays costs

In this case there will be no increase in the disease burden incurred by the individual. At a population level the health and social care costs will be delayed and the proportion of the population incurring them at any one time may therefore be reduced.

An intermediate possibility is that disability may arise at the same time but may develop more slowly. Woe increases with the extra years but not by as much. We live longer and the extra time is partly spent enjoying more life and partly spent taking more time to die.

ageing population costs postponed

In this case there will be some increase in the disease burden incurred by the individual and some increase in the health and social care costs incurred by the population, but it will not be anything like as great as in the first scenario.

The most optimistic scenario however is that we will live longer and we will spend less of that time ill. For each extra year of life there will be fewer years of woe. We will live longer and die quicker. My preferred mode of death is to be shot by a jealous lover at the age of 104.

ageing population with less disability

If this scenario is correct then the lifetime disease burden on the individual becomes less as life expectancy increases – we have the double benefit of living longer and suffering less. Health and social care costs for the population are both diminished and delayed – again a double benefit.

The theoretical basis for the nightmare scenario (longer life more disease) is that as people avoid the causes of premature death – infections, accidents, heart disease, violence, famine – they come to live long enough to suffer from chronic diseases and as a result to suffer a greater and longer disease burden.

It is certainly true that people have to die of something and that diseases that are commoner in older people, such as cancer, increase in incidence as diseases that kill a lot of young people decline. But the theoretical basis for the delayed disease scenario (longer life, same amount of disease) is that there is no particular reason to suppose that these diseases will cause a greater burden. Most people make most use of health care in the year before their death. This is true whenever that death is. Therefore if most people die when they are old that is when most health care costs will occur. It has nothing to do with age – it is related to proximity to death.

The optimistic scenario (longer life less disease) was first put forward by Fries and became known as the compression of morbidity scenario. Fries believed that if death from disease were avoided people would eventually die of old age. He believed there was a natural age of death which varied for each individual but was normally distributed around an age that increased by a few months each generation, having been three score and ten in biblical times and now being four score and five. This was genetically programmed, probably in the part of the chromosome known as the telomere. We would not be able to increase this maximum longevity, apart from the few months by which it naturally increased each generation, until we were able to genetically re-engineer the telomere, at which time massive extensions of longevity would occur. Until then all increases in life expectancy would be achieved by increasing the proportion of the population who survive to the maximum longevity. Death from old age is, Fries argued, quick. Hence if more people survive to reach this maximum age the total amount of morbidity would be reduced.

An alternative theoretical perspective, without the concept of a maximum longevity, but still with the perspective of compressed morbidity, views ageing as a harmonious deterioration of organ systems which diminishes resilience and increases the probability of death. Old age brings “frailty” – a term used here with the particular meaning that people are fully healthy and fit but are less likely to recover from factors which disturb that health and fitness. Improving population health delays people experiencing the disease that will kill them. The older they are when they encounter that disease the less resilience they will have and the shorter their death will be. On this basis the compression of morbidity consists of somebody living on, fit and well, into old age until they die suddenly of a disease or injury which a younger person would have recovered from.

In a theoretical population with no migration and a fertility rate that maintained a constant population the proportion of the population experiencing the need for health and social care associated with the disability and dependency of old age would be given by the formula:

Life expectancy minus healthy life expectancy

Life expectancy

As life expectancy appears in the denominator of this equation then an increase in life expectancy will in itself reduce the proportion, provided it is matched by an increase in healthy life expectancy so that the numerator doesn’t increase.

For example:

Life expectancy Healthy life expectancy Proportion needing care
70 65 7.1%
80 75 6.25%
90 85 5.5%

The increasing 20 years life expectancy (from 70 to 90) with an unchanged gap between healthy life expectancy and life expectancy (5 years) has reduced the population burden by 1.6 percentage points out of 7.1 percentage points, a reduction of 22.5%

However changing healthy life expectancy affects the figures even more spectacularly:

Life expectancy Healthy life expectancy Proportion needing care
75 65 13.3%
75 68 9.3%
75 70 6.7%

An extra 5 years of healthy life expectancy with constant life expectancy of 75 reduces the population burden by half.

If compression of morbidity occurs these two effects would operate together reinforcing each other:

Life expectancy Healthy life expectancy Proportion needing care
75 65 13.3%
80 75 6.25%
90 87 3.3%

It must be emphasised that these are theoretical figures which address only the non-demographic component of an ageing population. The increases in need due to demographic ageing also need to be taken into account.

There is real evidence to support the compression of morbidity theory. The gap between healthy life expectancy and life expectancy is lowest in areas with the highest life expectancy. People in such areas not only live longer but they experience less sickness in that longer life.

THE IMPLICATIONS OF THE ABOVE ANALYSIS FOR RESOURCE ALLOCATION

The above analysis suggests that the burden of an ageing population will fall most heavily on those areas with the lowest life expectancy. Resource allocation for both health and local government currently assumes that the burden of an elderly population falls most heavily on areas with the largest chronologically old population. This neglects the fact that in deprived areas people become sick sooner and are dependent for longer within that shorter life. Current resource allocation policies therefore direct the resources available to deal with an elderly population to the wrong areas. Apart from areas which have high elderly populations because they are popular areas for retirement, the areas with the largest chronologically elderly population will be those where people live longer and have correspondingly shorter gaps between healthy life expectancy and life expectancy.

A striking example of the difference between chronological age and dependency is given by the difference between two alternative formulations of the dependency ratio.

If the dependency ratio is formulated as

People over the age of 65

People of working age

it is at its highest ever and will inexorably continue to rise.

If however it is formulated as

People within 15 years of life expectancy

People in work

it is at its lowest ever and not likely to increase significantly in the near future.

This is partly because as life expectancy increases the age at which people enter the numerator of the second ratio also increases. It is also because of increasing female participation in the workforce and increasing participation in the workforce by people over the age of 65.

WHAT CAN WE LEARN FROM CENTENARIANS AND POPULATIONS WHERE AGEING WELL IS NORMAL?

There are a number of populations in the world where it is much more common for people to live to over 100 and to remain healthy well into old age – Okinawa, Sardinia, some Seventh Day Adventist communities in California, Georgia, and some remote valleys in Ecuador and in Pakistan. These communities have been the subject of study as have centenarians in a number of different countries.

About two thirds of centenarians demonstrate compression of morbidity, remaining fit and active well into their 90s so these groups definitely demonstrate a desirable characteristic. About 30% of the chance of living to be over 100 seems to be genetic but about 70% seems to be environmental. The best documented environmental factors are a healthy diet, exercise (and especially remaining active into old age), social support networks with a strong marriage and good friendships, a strong sense of personal identity with a goal to life, and some element of continuing challenge.

CAN WE PROMOTE HEALTHY AGEING?

One strategy to reduce health and social care spending is to promote healthy ageing. Can we do this?

A healthy ageing strategy must

  • encourage people to live the kind of healthy life described in the preceding section, especially to remain active into old age, to maintain friendships and a purpose to life, and to continue with healthy lifestyles, such as healthy diets.
  • ensure that people are not encouraged to accept that they suffer from old age when in fact they suffer from treatable illness.
  • make it easier for old people to remain active and involved
  • support people in staying independent when old age does begin to affect them

The Role of Healthy Lifestyles

The idea that it is too late to worry about good health when you are old is simply wrong. The drive to maintain healthy lifestyles must continue throughout life.

The Role of Expectations and Age Discrimination in the NHS

When I was 58 I began to develop some trouble with my ankle. I found it difficult to walk uphill. I commented to my wife that I felt like an old man when I walked up hill. I was fine when I walked on the flat or swam. However I did have two episodes where the ankle became swollen and painful.

I went to see a physiotherapist. She told me that there was restricted movement in the ankle probably as a result of an old injury in my twenties. She gave me exercises to carry out. Most importantly she advised me to force the ankle to bend when I was walking uphill.

I carried out the exercises. The ankle got a lot better. It still isn’t right. I still have to force it when walking uphill, and I still walk more slowly uphill than I would like. But my life is in no way restricted.

Imagine that I had had the idea that life ends somewhere in your 60s and that by your late 50s you are coming to the end of your life. Many people have that idea, especially in poorer areas. Being 58, I would just have accepted that I couldn’t walk uphill. I would have stopped walking uphill. I would therefore have walked a lot less. I would have become less fit. I would fairly soon have stopped walking. A downward spiral would have gathered pace, all of it as a result of one eminently treatable and not very disabling start.

Suppose that the health professional I had gone to see had said “Oh, it’s just your age”. I would have been a bit distressed that I was wearing out so quickly. I would have felt upset to abandon my ambition to be shot by a jealous lover at 104. But I would undoubtedly have resignedly accepted reality. Except that it wouldn’t actually have been reality. Although it would rapidly have become so as I accepted it as such.

An immense amount of harm and premature ageing is caused by people accepting treatable illnesses as old age and restricting their lives instead of tackling the problem. Often people do this because of a culture that tells them that life ends in your 60s and you are lucky if you reach your three score and ten. We have to fight that attitude and substitute for it a culture which says that you shouldn’t even consider being old until you have reached four score and five and even then think twice about it.

However people often abandon their active lives because the NHS has told them that a treatable condition is “just your age”. This is something we have to root out and bring to an end. It is essential that we take steps to stop this error being made. It is a common error that has devastating effects and that we have to stop.

Experiential training of front line staff can assist with shifting cultural thinking.

The Role of Well Being

Of the five factors which the studies of centenarians and of long lived populations showed to be most strongly associated with a long healthy life, three are elements of well being – social support networks with a strong marriage and good friendships, a strong sense of personal identity with a goal to life, and some element of continuing challenge. A fourth – exercise – is well known to be a factor which promotes a sense of well being.

From an ageing well standpoint it is important that old people are encouraged to retain a place in the world and a goal in life. It is also important that old people maintain social networks, friendships and leisure activities.

From a standpoint of preparation for ageing it is important that these aspects of mental well being play an important part in health improvement programmes.

Iatrogenic Ageing

Iatrogenic ageing is ageing which is produced by failures of health care.

The point made above about misdiagnosing treatable conditions as due to old age is one example.

Another is failure to recognise that there is clear evidence that physical activity is a highly effective treatment for frailty, and is indeed probably the only really effective treatment available. Advising people to reduce physical activity when they become frail, in some misguided attempt to protect them from risk, is seriously wrong.

A third form of iatrogenic ageing was described by Doctors in Unite in section 13 of its evidence to the House of Lords Select Committee on Long Term Sustainability of the NHS:-

  1. The burden on the NHS is increased by the failure of social care systems to provide effective crisis intervention leading to people presenting to the NHS. This is well recognised.
  2. Equally important but less well recognised is that the burden on social care is increased by failures of the NHS to intervene early to prevent the development of dependency – a process which is increasingly coming to be called iatrogenic ageing.
  3. The following is a scenario which will be played out in a number of places in the country today and every day.
  4. An old person who lives alone falls or feels unwell and is unable to look after themselves. They need no more than some temporary support but, being unable to arrange any form of crisis care, they or their neighbours or their out of hours GP, sends them to hospital.
  5. The hospital admits them to a busy ward with overworked staff.
  6. Their nutrition and hydration are neglected by busy staff and nobody has time to mobilise and walk them.
  7. As a result they lose mobility.
  8. Lacking mobility they are unable to be sent home.
  9. After a period of time the hospital starts to say that they have no medical need and to demand that the social care system finds them a place in a care home so that they no longer “block a bed”. However there are no community social care facilities available as they are either closed down or full. The patient remains in the hospital bed and other acutely unwell patients have to be kept in A&E or in corridors.
  10. Failing to invest in crisis intervention and intermediate care options to keep people out of hospitals, in staff to pay attention to the nutrition and hydration of people in hospital and in staff to mobilise old people in hospital, is stripping the lead off the roof to make buckets to catch the rain.
  11. When people start to become dependent they will initially want to support themselves at home. Support for this will slow the increasing dependency. Inadequate support will turn the home into a lonely place as constraining as any institution. Domiciliary support has been cut to this point already. Like failing to invest in hydration, nutrition and mobilisation in hospital, it is a false economy, stripping the lead off the roof to make buckets to catch the rain.
  12. When people do become unable to maintain a satisfactory lifestyle at home they need to be cared for in a dynamic vibrant community (what Nye Bevan, referring to the service that private hotels in the first half of the 20th century provided to those old people who could afford them, described as “the private hotels for the working class”). As one of our members put it “one of the most awful things we see is an old, vulnerable and helpless person stranded in their own home, visited by professional carers four times a day, unable to get out of bed and completely at the mercy of whoever has the number for the key safe. What a terrible existence. I am going into a care home with a lot of other raucous old ladies. I don’t want to moulder away unnoticed in my own home.”
  13. Unfortunately year by year pressures on the unit cost of care homes means that they often have to reduce the features which make them a vibrant community. There is some reason to believe that social pressures which focus on looking after people rather than on promoting their independence add to this pressure, as do CQC inspection regimes which have that same mindset. There is a place, albeit probably a limited one, for co-residency, where groups with different needs live together in mutual support. We are concerned by the uncomprehending way in which the CQC approached such a situation at Botton Village in Yorkshire.
  14. We need vibrant communities of old people and we need effective domiciliary care which delays the point at which people need to enter them. We are in grave danger, if current funding approaches continue, of having neither of these. If we do not have them the burden will fall on the NHS. We will once again have stripped the lead off the roof to make buckets to catch the rain.

CONCLUSION

Demographic ageing increases health care costs but ageing due to an increasing life expectancy reduces them. We are experiencing both of these processes at the moment. The balance between them can be improved by processes of healthy ageing including addressing the problem of iatrogenic ageing. Short term financial pressures undermine this and worsen the problem – stripping the lead off the roof to make buckets to catch the rain. Because of the failure to understand the difference between demographic and non-demographic ageing current resource allocation processes seriously misallocate resources to the unfair benefit of affluent areas and the unfair disbenefit of deprived areas.

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A repeated claim made by politicians and a justification for the Health and Social Care Act 2012 is that the NHS is ‘unsustainable’ in its present form because the UK’s ageing population is increasing costs to levels that we can no longer fund from taxation. But this is a myth. While the proportion of the population aged over 65 years is increasing in most of the developed world as people live longer, there is no evidence for the claim that ageing itself will lead to a funding crisis. Rather, the NHS funding crisis is due to cuts in funding for the NHS and social services coupled with the high costs of marketisation and privatisation leading to service closures such that NHS funded services including GP services and out of hours services and hospital services are no longer meeting needs.

Reductions in funding and budgets for social services and long-term care and reductions in local authority provision add to the strain on NHS services. The volume of services provided is shrinking and these are not keeping pace with need. The amount spent on social care services for older people has fallen nationally by £1.4 billion (8.0%) from 2010-11 to 2012-13. The number of people receiving state-funded care fell from 1.8 million in 2008-9 to 1.3 million in 2012-13.

According to Age UK, in the three years between 2010-11 and 2013-14:

  • Numbers of older people receiving home care have fallen by 31.7% (from 542,965 to 370,630).
  • Day care places have plummeted by 66.9% from 178,700 to 59,125.
  • Spending on home care has fallen by 19.4% from £2,250,168,237 to £1,814,518,000.
  • Spending on day care has fallen even more dramatically by 30% from £378,532,974 to £264,914,000.

Older people are living longer, healthier and more productive lives

The extent, speed, and effect of population ageing has been exaggerated by the government because the standard indicator—the old age dependency ratio  ( The old-age dependency ratio is the ratio of people older than 64 to the working-age population, aged 15-64) — does not take account of the fact that people aged over 65 years are younger, fitter and healthier than in previous decades. In fact older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years.

Currently over one million older people are still working, mostly part time, many with valuable experience or specialist knowledge. The spending power of the ‘grey pound’ has risen inexorably. Many do volunteer work vital to the third sector or look after grandchildren.

Older people aged over 65 contribute more to the economy than they take out. It is estimated that taking together the tax payments, spending power, caring responsibilities and volunteering effort of people aged 65-plus,older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services.

Most acute medical care costs occur in the final months of life, with the age at which these occur having little effect. It is not age itself, ‘but the nearness of death’ or health status of the individual in the ultimate period in the last few years or even months before death that matter most. According to this hypothesis health expenditure on older age groups is high, not so much because their morbidity or disability rates are higher, but because a larger percentage of the persons in those age cohorts die within a short period of time.

Similar findings have been reported in other European countries where by 2008 it was shown that ‘contrary to popular belief, ageing is not an inevitable and unmanageable drain on health care resources.’ Indeed one study suggested that the cost of death declines with age because older ‘people tend to be treated less intensively as they near death.’ In fact, it is those dying between the ages of 50 and 60 who cost the most. If the cost of death declines with age then an ageing society could lead to lower health care costs.

Life expectancy is an estimate of average expected life span, healthy life expectancy is an estimate of the years of life that will be spent in good health. The trend for healthy life expectancy at 65 in England for males and females has increased approximately in line with overall life expectancy at 65. For example, between 2006 and 2009, healthy life expectancy increased by 0.8 years for females and 0.5 years for males while overall life expectancy grew by 0.6 years for females and 0.7 years for males. This suggests that the extra years of life will not necessarily be years of ill health. There are important socio-demographic differences in healthy life expectancy. Not only can people from more deprived populations expect to live shorter lives, but a greater proportion of their life will be in poor health.

When measured using remaining life expectancy, old age dependency turns out to have fallen substantially in the UK and elsewhere over recent decades and is likely to stabilise in the UK close to its current level. It is not age but nearness to death that accounts for health expenditure.

Increased life expectancy means more years lived in good health.

Politicians must stop blaming older people for their decisions to cut funding and close services

The false premises of the ageing hypothesis provide a technical rationale for starving the NHS of funds. In July 2013 NHS England warned of a funding gap ‘of around £30 billion between 2013-14 and 2020-21’. A Lords select committee , the Office for Budget Responsibility , the Nuffield Trust and the Institute for Fiscal Studies published health spending projections on the assumption that ageing is a main driver of cost rises. The studies mainly relied on simple population projections. The connection between ageing and costs and chronic illnesses was simply assumed. They did not consider the fact that people are living longer, healthier and more productive lives.

So the most remarkable thing about the ageing hypothesis or ‘demographic time bomb’ is its survival. The Canadian economist Robert Evans has described it as a ‘zombie theory’, one that refuses to die. It survives today only as a reason for explaining politicians’ bad policy decisions which have resulted in pressures on the NHS: as an alternative to the real reason which is the cutting of health budgets, and services for health care.

In the UK, both the Royal Commission on Long Term Care (the 1999 ‘Sutherland report’) and the Wanless Inquiry (2001-04) rejected the ageing thesis. The 1999 Royal Commission found that, even though ‘the population aged 80 or over is growing rapidly and appears likely to continue to do so’, the UK was not on the verge of a “demographic time bomb” as far as long-term care is concerned and as a result of this, the costs of care will be affordable.’

Wanless concluded: ‘Despite this significant ageing of the population, demographic changes have so far accounted for a relatively small proportion of the increase in spending on health care in the UK. While overall spending (between 1965 and 1999) grew by 3.8 per cent a year in real terms, the demographic changes alone required annual real terms growth of just 0.5 per cent a year. Less than 15 per cent of the growth in health care spending over the past 35 years can therefore be attributed to the cost of meeting the needs of an ageing population. This is in keeping with findings from other countries.’

In Canada the Evans paper on the Romanow report into future health care costs declared: ‘All studies come to the same conclusion. Demographic trends by themselves are likely to explain some, but only a small part, of future trends in health care use and costs and in and of themselves will require little, if any, increase in the share of national health resources devoted to health care.’

The European Commission report of 2010 found that it was ‘the health status of an individual (and – in aggregate terms – of the population), rather than age itself, which is the ultimate driving factor’ behind cost rises. Furthermore, ‘Over time, there is no clear link at the aggregate level between levels of spending on health care and the demographic situation of societies. In fact, several studies have found that the impact of ageing on increase in health expenditures is limited to as little as a few percentage points of this increase.’

The connection between ageing and health care costs has also been rejected in studies and parliamentary reports in the USA, Canada, Germany and Australia.

Examples of the ‘Zombie theory’ and how it is used to justify policy choices:

“We’ve got a growing and ageing population now and this is having a significant impact. It’s down to the policy-makers to decide whether to change the policy or not.”  Rupert Egginton, director of finance at the Nottingham University Hospitals NHS Trust

“An ageing population with more chronic health conditions, but with new opportunities to live as independently as possible, means we’re going to have to radically transform how care is delivered outside hospitals.” Simon Stevens, Chief Executive of NHS England

“However, if the NHS is to meet the needs of an ageing population we need it to be more efficient so it can provide more and better treatments.” Lord Howe, Parliamentary Under-Secretary of State for Health

Trends in numbers of people aged over 65 years and mortality rates and number of deaths:

ageing population

Figure 1: Age-Specific Mortality Rates, 1963 and 2013, England and Wales (Source: ONS24

Figure 2: Age-standardised mortality rates (ASMRs) in England and Wales, 1942-2012 (Source: ONS25)

Figure 2: Age-standardised mortality rates (ASMRs) in England and Wales, 1942-2012 (Source: ONS)

ageing population

Table 1: Number of deaths registered in England and Wales, 2004-2013 (Source: ONS)

Age structure of the UK: 2011 Census data

  • Aged 65 and over: 10.376 million
  • Aged 85 and over: 1.394 million
  • Total population: 63.183 million

This was first published by the Campaign for the NHS Reinstatement Bill

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You need to be rich these days to grow old with dignity in Britain. Six years of local authority budget cuts by the conservative government has placed the burden for caring for our elderly and infirm on their relatives and the over-stretched voluntary sector. Since the Tories came to power, local authorities have responded to these central cuts by allocating 9% less on social care, as demand has grown.
As the government abandons our most in need, a silent alarm is screaming in households across the country.  Hundreds of thousands of Britons who struggle to eat, wash and go to the toilet are left to make do. A daily trial, a daily injustice. Access to care now depends increasingly on what people can afford rather than on what they need because the poor are more reliant on the state.
A report published by the King’s Fund this week puts the social care funding gap by 2019/20 at £2.8 billion as public spending on it falls below to 1 per cent of GDP. It predicts that that many of thousands of mostly small and medium sized businesses that make up most of the care sector will fail due to the reduction in government grants to the local authorities which pay them. “The possibility of large-scale provider failures is no longer of question of ‘if ’ but ‘when’ and such a failure would jeopardise continuity of the care on which older people depend,” says the King’s Fund.
The social care funding crisis has had the knock-on effect of precipitating another crisis within the NHS because elderly people with nowhere to go are filling A&E departments and hospital wards across the country. The government is depriving the health and social care systems of the money they need to function, leaving it up the blood, sweat and tears of staff to keep our once great NHS together. There is nothing accidental about this crisis. The government is deliberately precipitating shocks in the system so it can bring about its own solutions, which invariably involve more privatization, deregulation and cuts. If the government wants to derogate from its duty to provide care for a growing number of older people in Britain, it must come clean and say so.The alarm cannot ring silent forever.
Labour believes it is the state’s role to provide basic social care for old people with no money. We will be honest with the public about the unavoidable growth in demand on health and social care services from an aging population, and we will provide the finance required to meet these needs.

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I actually had no intention of doing any of this. To explain, I am the primary carer for a close relative of mine in hospital.

This week, I had to get a close relative in as an emergency to a large local NHS teaching hospital here in London.

I came across islets of great care. All the nurses were working around the clock. The clinicians looking after my relative indeed showed the 6Cs you’d wish for. The porters who wheeled my relative to investigations were very pleasant when I happened to be there; not stand-offish and very human.

This teaching hospital in fact saved my life in 2007, so I come to the situation with no malice at all. Quite the reverse, I have substantial respect for the staff there.

But there were aspects of really ‘not great’ care which came to my attention which alarmed me. I was close to coming to make a formal complaint, and indeed received the pack from PALS. The purpose of this complaint was to ensure that my concerns did not bubble under the radar, but actually got trapped into the corporate governance systems. In the end, none of this was necessary as my relative received a new consultant, and I had an open discussion with him and two senior nurses on the ward. They took on board my concerns, and the new Consultant who is a geriatrician described my suggestions for improvement as very good.

As a Member of the Royal College of Physicians of London myself, and fully on the medical register, I cannot interfere with my relative’s clinical issues. But sitting as a relative was stressful for me, watching aspects of bad care reveal themselves.

Last week, a cannula was ‘seen’ and not attempted – and delayed by several hours. I can’t reveal what subsequently happened due to confidentiality. As a spectator, this made my ‘carer experience’ worse.

Last week, a junior sister told me off for turning up ten minutes early for visiting hours (2 pm – 8 pm). In explaining herself, she said (verbatim), “she was well within her rights to enquire” – and then progressed to tell me nothing about John’s Campaign nor the RCN’s “Triangle of Care’ which puts at the heart of care a carer, professional and patient.

A few days ago, a medical student tried another cannula. He failed, said he would be back in 10 mins, and never returned. I then asked an hour later to the nurse why the cannula was needed. She said she had no idea. I asked her to ask the medical student whether it was still needed. The nurse looking after my relative said, ‘The medical students says it’s all sorted now.’ 20 minutes later, a porter came to take my relative for a scan, but then it transpired she needed the cannula for that. The junior doctor then explained to me for the first time why the cannula was needed. I went with my relative for the scan, returned, while my relative waited downstairs for a porter. In the meantime, my relative missed an investigation on the ward. I returned an hour later after meeting somebody totally different. On my return at 6 pm, I witnessed a third person attempt the cannula for the investigation which had been bounced to the following day.

It does nauseate me there does not seem to be people who are able to do cannulas in a timely manner on the ward, but this is actually the least of my worries.

I witnessed many examples of patients with cognitive problems not being able to remember interactions on the ward rounds. Ward rounds tended to happen in the morning, when I was not actually allowed onto the ward due to visiting hours. I witnessed other patients being taken off to investigations without any explanation at all – literally being treated as if they were cattle to be transported. I was on a ward round when a Consultant did not even bother introducing himself to me, even though I was there as a relative. Until yesterday, no medic or nurse had involved me in any shared care of the relative, as would have been consistent with the RCN’s “Triangle of Care” guidelines. I witnessed patients being seen by different clinicians every day, totally disorientating for them as they were clearly in an acute confusional state anyway. This is not person-centred care.

But there is hope. The Trust has completed a successful pilot of a handbook for all staff including porters on dementia. It’s brilliant and contains advice – such as the need to be aware that people with dementia might not communicate effectively they’re actually in pain. There will soon be a therapeutic massage service, to help with the wellbeing of carers of people with dementia. A ward somewhere there has special lighting, conductive to improved wellbeing for people with dementia and carers. And they will tentatively roll out John’s Campaign – for people with cognitive impairments who need to have a patient advocate there, this is not a luxury – this is a necessity.

I think also what made a difference was the consultant looking after my relative from yesterday being a Fellow of the Royal College of Physicians, and being dually accredited in general and geriatric medicine. The previous physician was a (good) jobbing physician for adult general medicine, but one who did not introduce himself – and he seemed more concerned about showing off to his juniors whom he called ‘boys’. That doctor in question could have concerned himself with various clinical issues of my relative, which are some of the ‘geriatric giants’. The geriatrician instead crossed off unnecessary investigations and drugs – was entirely practical – and was very keen on preventing further acute hospital admissions, improving wellbeing, and setting up a proactive support in the community for the clinical problems facing the relative.

The new consultant geriatrician viewed my relative to be independent, whereas the three AHPs who had seen my relative had tried my relative out on various mobility aids which she in fact totally hated. My conversation with the social worker was superb, contrary to my expectations. The nursing staff had thought for a week that my relative lived alone. So it was with some amusement that the new Consultant said pointedly yesterday to all of them in our formal meeting together that I lived with her.

So – progress.

I think ‘whistleblower’ is an unnecessarily strong word for the situation I found myself in. But all feedback is gold dust for the NHS, I now strongly believe. I also recommended a point of contact for all relatives. Nobody on the ward ever introduced themselves on the phone with their names or responsibilities. I thought originally the #hellomynameis campaign was a bit gimmicky, but now I 600% see where Kate Granger is coming from.

A note to this Trust – please do not treat carers as invisible, and do not treat patients as targets of investigation and speciality follow-up merely. They are persons with their own beliefs, concerns and expectations. And above all, I am pleased senior people at this Trust were utterly brilliant in acting on feedback.

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Supporting older people towards independence

The majority of older people wish to remain independent and live in their own homes for as long as possible. Instead maintaining a cruising altitude however, the process of ageing forces many to descend towards dependency and long-term care.

It’s never too late to learn new ways for coping by yourself and to make preparations for independent living in older age. But it is a shame that too often these good intentions are superseded by doubts and avoidance. We need to ask who is doing sports regularly at 72 when in general this is considered appropriate for “boys and girls”? Who is investing in making new friends at 78 when some of their loved ones have passed away?  Who is shopping with a neighbour for comfort and security at 85? These types of activities form the ultimate recipe for how older people can remain independent and in their own homes. Far too often we are just waiting for deficiencies to present themselves, listening only when people ask for help and then responding with long term care provisions. There is a growing literature showing that it is almost never too late to benefit from specific interventions which they address the physical, psychological or social aspects of everyday life.

In Denmark since the beginning of 2015, it is mandated by law that municipalities should offer ‘reablement’ services when their citizens apply for assisted services. The basic idea is to deliver a transformative change in the health-services sector towards empowering citizens to do things for themselves rather than doing it to for them. Cynics view these services as an impingement on their personal rights and consider it a moral excuse for government to implement yet another round of austerity measures. But is there any sensible argument against enabling citizens to pursue their personal goals and remain independent?

My personal epiphany was whilst I was visiting Jutland in 2011. The Danish municipal workers taught me how they deliver ‘restorative care’. They introduced me to an 82-year man who had experienced a family bereavement not long before. I knew from my surgery and statistics that he suffered a very high risk of adverse outcomes. He was offered an intensive, six-week intervention focussing on supporting him to regain skills like washing, ironing and cooking; in other words the skills to be able to take up life again.

Reablement just seems like the right thing to do which begs the question, why do we feel so uncomfortable with the idea?

First published on the British Geriatrics Society blog

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If Labour wants to go beyond opposing austerity and thereby appeal beyond the 25% of voters  affected directly, then it needs to propose policies that are relevant to the fears and dreams of specific sectors.  However, this needs to go beyond promising to do the same thing as the Tories only better, and policies should neither look like mere electoral opportunism nor be reducible to it: there needs to be a good reason for such promises.  And while it is important to defend the good in Labour’s record, new ground will need to be broken if there is to be a harvest.

The Tories have garnered votes from the older sector of the population who have gained financially and disproportionately.  But with social care in crisis, there is a potential opening for Labour.  Just as the 1948 foundation of the NHS responded to fears of illness and not being able to afford (medical) care, so Labour now could respond to fears of becoming old and frail and ending up either discarded, unsupported or surviving in a below standard service, staffed by ill-trained, badly managed staff on poverty wages.

So, the idea of a National Care Service (proposed towards the end of the last Labour government by Andy Burnham) is one whose time has come.  But that National Care Service needs to offer something distinctively new, overcoming the stigma and second class treatment so typically experienced by those who have to rely on formal care and support.   Bevan didn’t produce any “costed plans” for the NHS, and Labour should make it clear that this is a matter of caring for people, not saving money.  However, it could also indicate how the service would be funded and organised.  So from the outset any proposal needs to be explicit about values, show how it links with other fields of policy, and give some clues about organisation and funding.  As I see it, some of the dimensions would be:-

  • An end to the means test for social care funding and the government claw back of people’s savings. In my experience this corrupts assessments and understandings of people’s needs.
  • Funding would be by exploiting government’s ability to borrow at advantageous rates and/or the ability to spend money into existence (as per People’s QE if the conditions are right).  That’s very different from reliance on private finance, or indeed from the present arrangements where operators are allowed a 12% return on capital invested.  Colleagues from Manchester Business School have provided some comparative figures for capital expenditure for the residential homes sector.  “..reducing the claimed return on capital from 12 to 5% allows either an 18% reduction in price or a 40% increase in wages or some combination of the two benefits. If the starting point is an 8% cost of capital, the benefits are smaller but something like a 15-20% increase in wages is possible by low-cost public borrowing”. Link to report – see pp.  pp. 71-76.
  • Funding of all/most social care should be on the same basis as the NHS (i.e. with only the most minimal co-payments, if any) to be funded as above and via improved tax take (and reverting to a progressive direct taxation model), as well as by scrapping Trident, cancelling PFI contracts, stopping subsidy for private capital (rail, fossil fuels,/aviation,, nuclear power, etc)…… bold, practical socialism.
  • A new deal for staff – proper training and decent pay – the Keynesian multiplier will in part fund this through improved tax receipts and (managed, selective) economic reflation.  That supporting and caring for frail, vulnerable and complex people should be seen as less deserving than other jobs, speaks volumes about the accounting values of our neoliberal society.
  • But if Labour’s National Care Service is just a well-funded and staffed “care service” it will be a failure.   The 1948 welfare state was hardly a model of how to support people with disabilities or physically and mentally frail elders.  It separated them from society, subjecting them to regimes where professional fiat was the least of the problems – serious abuse and neglect were common, despite the commitment and strong service ethic of many workers in those services.  So what is needed is a transformation of care and support, fit for the changed society we now live in.
  • This means a new deal for older people with an emphasis on valuing and celebrating their contribution – with a “just enough” model of support – too much assistance is nearly as bad as too little: the trick is to get the level right, and this means using resources wisely and preventatively.  That would be  based on a neighbourhood model of domiciliary care as the first option, provided by public sector staff (but with new models of the public beyond local and national government bureaucracy).  Support for what though? Support to live a meaningful life, to pursue interests, to take part.  The proposal here means a downsizing of residential care, which is happening anyway as firms go out of business, but with a variety of other options developed.
  • In the longer term this means reducing the isolation and ghetto-isation of older people – new housing developments must include extra support schemes and be designed to allow the titration of support against increasing need, without the person having to move unless they want to, or it really is impossible to offer support safely and maintaining dignity.
  • To complement a truly inclusive approach, there is a need to support and fund intergenerational initiatives, based on old and young sharing time and activities together.  That would build on but go far beyond existing initiatives like literacy and numeracy volunteering in schools.  In a recent interview, Jeremy Corbyn described two of the volunteers in his leadership campaign, a hijab-wearing 18 year old showing a ninety year old how to use a mobile phone.  No doubt the older woman was also able to pass on a lifetime of practical intelligence.  How can we make this the norm, recovering something lost as our society became more specialised, more modern?
  • Social infrastructure can support much of this with emerging models such as co-housing and home-share.  This could help more older people stay in their own homes, offering accommodation in return for a level  of support – but being careful to match that support on a sliding scale with State-funded professional, formal input.

Much of this is not new: some of the thinking was there in the March 2010 White Paper “Building the National Care Service”, but I am proposing a change of emphasis. To summarise:

Firstly, although properly funded and organised services are vitally important, the problems of social support and care do not reduce to service provision: they have to do with the position of vulnerable people in our society.  They are citizens not “service users”, whatever their needs, and a socialist approach needs to begin with a hunger for social justice.  This is not about “independence”, the illusory self-sufficiency that (neo)liberal society so values (with its fantasy of dependency reduction through various magic and not so magic bullets), but about interdependency, or perhaps better, shared or pooled dependency, where we are all at various stages in a cycle of waxing and waning dependence and contribution.

Secondly,  older people, and others with disabling conditions are only part of the electorate.  Labour needs a Whole Policy approach, and the SHA needs to emphasise this – balkanising either/both health and social care (and prevention) from the organisation of society and economy as a whole is a recipe for failure inevitably leading to a discourse of affordability, compromise and efficiency.  If Labour’s new path means anything, it is a break from this.

Taking these two points together, it means a simultaneous emphasis on high quality, properly funded provision and a society that looks after us all, not just by offering a service, but through its very everyday fabric: part of what NEF call “a new social settlement”.

A very bold initiative, plausibly costed, with an inspiring model and vision, that responds to people’s fears while appealing to their dreams, could fill part of the policy gap between fighting austerity and offering a society a majority can believe in.

Mark Burton was for many years a manager of integrated health and social services in Manchester.  Now retired he works mostly on alternatives to the economic growth in public policy.

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There’s no escaping the fact that your body will change as you get older. From your sex life to the appearance of your skin, age can affect you in a variety of ways. Here, we take a look at three important areas of change, and offer advice to help you combat some of the ill-effects associated with growing older.

1) Sex can become more difficult

It’s a myth that sex is a young person’s sport. In fact, age is no barrier to enjoying active physical relationships. Highlighting this fact, a survey conducted by Saga revealed that 65 per cent of the over-50s are sexually active, and 85 per cent believe sex is less pressurised than when they were younger, meaning it can actually feel better. However, there are certain physical problems that can make physical intimacy more difficult as we age.

For example, while between seven and eight per cent of men aged 20-40 experience erectile dysfunction (ED), this figure increases to 40 per cent in the over 60s, and in those aged 70 and above, it rises to over 50 per cent. ED can be triggered by potentially serious underlying medical complaints like diabetes, high blood pressure and heart disease, so if you are suffering from this condition, it’s important to speak to your doctor. You might also benefit from taking targeted ED medicines like Viagra, and you can get more information about your options from your doctor or by visiting specialist websites such as https://onlinedoctor.lloydspharmacy.com.

Women can also be more prone to sexual difficulties as they get older. The menopause triggers a drop in oestrogen levels, and this can cause pain during intercourse and a reduction in arousal. Research has found that more than eight in 10 menopausal women find sex uncomfortable. You don’t have to simply put up with these problems though. Treatments such as hormone replacement therapy can help, and even something as simple as using a lubricant can make sex enjoyable again.

2) Your risk of obesity and heart disease rises

As the years pass, you might find yourself gradually doing less and less exercise. If you lead an inactive lifestyle, rest assured you’re not alone. Many people aged 65 and over spend an average of ten hours or more each day lying or sitting down, meaning they are the least active age group. Being sedentary can lead to a range of problems. For example, it raises the risk of obesity and heart disease.

To help you control these dangers, it’s important to make an effort to stay as active as possible. You should aim to do at least 150 minutes of moderate exercise a week, and ideally this should be broken up so you do some activity each day. Attending aerobics classes, swimming, cycling and playing and sports like tennis can help you stay fit and healthy. Even walking to the shops or doing some gardening can keep your activity levels up.

3) The collagen in your skin degrades

One telltale sign of the passage of time is the development of more wrinkles on your skin. This happens because the collagen present in your skin naturally degrades as the years pass. However, there are ways to protect your skin and slow down this ageing process. For example, avoid over-exposure to the sun. Limiting your intake of alcohol and drinking plenty of water can help too.

You can’t stop your body from changing as you age, but tips like these can help you to avoid a host of health problems.

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By the time the NHS celebrates its centenary in 2048, there will be over 100,000 centenarians in the UK. A profound shift is well underway in the age structure of our population. We are becoming an older society.

Our health and care system would still be recognisable to Beveridge and Bevan. Hospital based, treating illnesses, patching people up. It is essentially a healthcare system designed for 1930s needs, when lives were shorter and communicable and childhood diseases dominated.

The healthcare needs of today are different. Non-communicable, often lifestyle related, diseases dominate. Many people have more than one long-term condition or disability. In old age the successful management of long-term health problems can make all the difference, avoiding the need for hospitalisation and reducing the risk of frailty and greater dependency on family and institutional care.

In 2014, NHS England’s chief executive Simon Stevens made the case for change in his Five Year Forward View. The report achieved a remarkable degree of consensus across the party divide and health professionals.

The report laid bare the financial challenge faced by the NHS over the next five years: a funding gap of £30bn by 2020. The government has pledged an extra £8bn funding by 2020, this is on top of the £2bn voted in the March 2015, but in exchange has asked for the NHS to make the £20-£22bn savings.

The efficiency challenge this represents is unprecedented. In his interim report on operational productivity in NHS providers, Lord Carter estimates that “savings of up to £5bn per annum by 2019/20”, could be achieved “provided there is political and managerial commitment to take the necessary steps and funding to achieve these efficiencies.” Carter’s £5bn is a good start but it demonstrates the scale of the task. Where will the rest of the £22bn come from?

Work by Monitor highlighted between £10.6bn and £18bn of potential productivity gains through changes to existing services, delivering the right care at the right place at the right time and implementing new ways of delivering care.

Despite social care spending falling by over 15 per cent between 2010 and 2015, contrary to what was set out in the coalition’s 2010 spending review, social care was crowded out by the NHS ‘debate’ during the 2015 general election. Three-quarters of that reduction in spending was achieved by reducing the amount of care provided.

Directors of Adult Social Services have warned of the fragility of the care marketplace. In 2011 when Southern Cross collapsed, banks and big providers rallied around to avoid a business failure turning into a human tragedy. Since then the Care Quality Commission (CQC) has been given new responsibilities in the event of provider failure. However, will the care sector rally around again if fragility turns to failure?

Health and social care are two sides of the same coin, yet the contrast between them is stark. Health funding has increased from £97.5bn in 2010-11 to £116.4bn in 2015-16, a 19.3 per cent increase. Over the same period, social care funding has decreased from £14.9bn to £13.3bn, a 10.7 per cent reduction, and more in real terms when demography is taken into account. We are heading for a shortfall of £7bn a year by 2020, according to the Nuffield Trust.

The over 65s are the biggest consumers of health and care services, accounting for 43 per cent of all emergency admissions to hospital and 44 per cent of planned admissions. For an older person 10 days in hospital can cost them 10 years of muscle loss. A wait of just two days cancels out the benefits gained from intermediate care. The longer a medically fit person lingers in hospital the frailer they become and the more remote the prospect of a return to the life they led before. Put another way, poorly performing hospitals are frailty factories shunting costs onto social care.

What to do?

There is no single reform, nor amount of money, sufficient to ensure we have an NHS fit for 2048. However, as Lord Rose recently argued in his report on ‘Leadership in the NHS’, a good starting place would be clarity of purpose.

The Care Act 2014 offers some pointers. It establishes a new organising principle for adult social care, namely the promotion of individual wellbeing. For too long, the physical, mental, social and relational dimensions of human health have been kept in discrete professional and institutional silos. The promotion of individual wellbeing should become the unifying purpose of public health, NHS and social work.

The Care Act also charged councils with a new duty to prevent and postpone dependency and frailty. This is essential to bend the demand curve for health and care services and it throws down the gauntlet of reform.

In 2012 the Local Government Association (LGA) embarked on an adult social care efficiency programme to devise and test comprehensive and innovative approaches to help make savings, protect services and deliver the government’s vision for social care. As the LGA’s reports document, a new model of social care is developing which focusses on interventions that enable people to recover, and maintain their independence and social connections.

Councils embracing this model have developed a new frontline for their adult social services. For example, in Shropshire the council has set up a social enterprise, People2People. Led by staff and users, it aims to work with its ‘customers’ to identify what is affecting an individual’s life, calling on this deeper knowledge to devise community-based solutions tapping into networks of local support.

This approach means that the council can offer practical support to far more people. A key marker of success is the proportion of these initial contacts that lead to workable solutions. Results are promising: 75 per cent of enquiries are dealt with at this stage avoiding the need for an assessment or an offer of formal help.

A similar approach has been pioneered by Sutton Council’s adult social services. Community social workers have the task of working with people to foster their own support networks, reducing social isolation.

Other councils have tried and tested a range of preventative measures to assist people in crisis, focussing on recovery, rehabilitation and recuperation. Success depends on a joined-up approach both between social services and the NHS, and within the NHS itself.

As well as overhauling NHS commissioning, the 2012 health reforms established health and wellbeing boards to promote integrated working. These boards have had mixed results so far. Some are fulfilling their potential and becoming system leaders shaping local health and care systems around shared goals, addressing the social determinants of ill health. Others have degenerated into talking shops, while some have failed even to find a common language to start the conversation.

The boards should focus on improving the wellbeing – health status – of the population they serve, challenging unjustifiable variation in performance and outcomes achieved.

It is still early days for the boards: evaluation is needed and investment in developing their capability to realise their potential as system leaders. If a transformation fund of the sort proposed by the King’s Fund were established as part of the 2015 spending settlement it should make such capacity building a requirement.

Getting the relationships right, building trust and systems leadership are prerequisites for the kind of devolution now being worked through in Manchester and Cornwall to succeed. While integration is essential to delivering better outcomes and better use of existing resources, it is not sufficient.

Two critical and often overlooked parts of the health and care jigsaw that have much to contribute are mental health and housing.

The independencies of physical and mental health in the management of long term health conditions and in the treatment of such things as heart disease or cancer has not been widely reflected in models of care. It has been estimated to cost the NHS £13bn a year, quite apart from the wider costs to society and the individual.

Appropriate housing can make a decisive difference to a person’s ability to live independently, as research by Aston University for the ExtraCare Charitable Trust has shown. Models of housing with care offer later life choices that can reduce the call on health and care services. This was recognised in 2014 with an agreement between the NHS, LGA and National Housing Federation, and health and wellbeing boards need to reflect this in the way they operate.

NHS England’s Vanguard programme offers an opportunity to prototype new ways of working that bring mental health, housing and social care into the mix. The Vanguards take forward some of the thinking in the Dalton review into options for providers of NHS care. But they must find ways to ensure that the local debates about organisational reform start with clarity about the shared purpose.

Much has been made of the Better Care Fund (BCF), established in April 2015. The fund is the biggest ever pooling of health and care resources. However, it is still a drop in the ocean and its goals, such as hospital admission avoidance and better discharge co-ordination, are short-termist.

A single budget covering all locally commissioned health and care services must be the goal. The BCF could become the vehicle for this, with health and wellbeing boards the driver. The BCF can help to break down the wall between health and care but that is just the beginning. The promotion of individual wellbeing requires bespoke approaches; what better way to achieve integration than at the level of the individual shaped by their lived experience through a personal budget.

A single budget for health and social care calls into question the ‘middleman’ role of the Department for Communities and Local Government, in distributing the social care spending ‘settlement’ reached by the Department of Health and Treasury. This role should be dispensed with and the Department of Health made responsible for a single settlement for health and care, and the settlement should be ring-fenced.

Until there is one shared purpose – a single spending settlement and a single budget – too many opportunities for transforming services and reducing demand for health and care will be missed.

There is a bigger economic case for investing in prevention and new models of care and health. As the number of people of a working, taxable age shrinks or becomes stagnant, causing gaps in the job market, the need to support longer working lives will grow. For many families the pressures of juggling both caring for frail parents and young children can become overwhelming and trigger a decision to quit work or reduce working hours. UK plc can ill afford to lose these sandwich generation workers.

Wellness and care services are a vital part of our economic infrastructure. Access to reliable and affordable household and personal services, including wellness services, can help families to cope and fulfil the wishes of many to maintain the normal patterns of daily living for as long as possible.

Debates about the ageing society tend to pose the questions in terms of ‘them and us’. Rather, we should talk about what we want for our older selves – a life well lived, opportunities to contribute and a good death.

This was first published by the Fabian Society

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There is a silent and largely-ignored army of 1.2 million people over 65 in the UK providing unpaid care to another person. The size of the army is growing, the pressures are increasing while support from the state is being withdrawn. Our society cannot function without the support of older unpaid carers and yet they are increasingly being asked to function without the support of society. A crisis is waiting to happen.

Carers provide unpaid care by looking after an ill, older or disabled family member, friend or partner. Some people find caring a rewarding experience because they are helping someone they love who has perhaps looked after them in the past. But when carers are themselves growing older and more infirm, when there is no other option, when care has to be given 24/7 without respite, when it cuts people off from their friends, the things they like doing and the wider society, and when it comes with financial pressures and debts, it can have a hugely negative impact.

Life expectancy is increasing. The conditions for which older people have traditionally provided  care are changing as people with stroke and Down’s Syndrome, for example, live longer. More older people are looking after even older relatives and many are co-caring; it is not unusual to find a mother of 95 looking after her daughter of 70 who has Alzheimer’s Disease.

Cuts in public spending are having a significant impact on carers in general and on older carers in particular, both as direct users of services and in relations to support for them as carers. Services in the community for older adults have seen the biggest reductions, with £539 million taken out of home and day care alone between 2009/10 and 2012/13. The number of older people receiving publicly funded services fell by 26 per cent (245,855 older adults) over this period.

In addition, there is a crisis among professional carers who are working for low wages in difficult conditions (eg zero hours contracts) and are being stretched to cover the amount of care needed by the growing number of older people, disabled people and severely disabled children and those who are in the workforce have very low wages and poor terms and conditions of service (eg zero hours contracts). Restrictions on immigration will worsen labour supply. Funding cuts have also affected voluntary sector organisations, making them, in turn, less able to offer support to carers.

All of this means that the burden of care is increasingly falling on older carers who are increasingly part of the human infrastructure that keeps our society, including our NHS, functioning while being under severe emotional, physical and financial pressure themselves.

Older carers: the facts

Poor co-ordination of data makes the impact of these factors difficult to quantify. But here are some of the facts that we do know.

  • There are 1.2 million carers aged 65 and over in England. Whilst the number of carers has risen by 11% since 2001, the number of those over 65 rose by 35%.
  • The number of carers aged 85 and over grew by 128% in just ten years. A larger proportion of those aged 85 and over in England and Wales were providing unpaid care in 2011 than in 2001; 8.8% in 2011 compared to 5.0% in 2001. Over half of those aged 85 and over who provided care in 2011 were providing 50 or more hours of care in an average week.
  • Nearly half (45%) of arers aged 75 and over are looking after someone who has dementia.
  • The most recent estimates show that the average saving to the state made by each unpaid carer is £18,471 each year. This would mean that the contribution of older carers is over £23.6 billion a year.
  • Two thirds of older carers have long-term health problems or a disability themselves. In the most recent survey of carers by Carers UK, 92% said that caring has had a negative impact on their mental health, including stress and depression. Carers providing round the clock are more than twice as likely to be in bad health than non-carers and this is likely to increase as carers get older.

The loss of earning, savings and pension contributions can mean carers face long-term financial hardship into retirement.

In 2014, half of carers (49%) said they feel society does not think about them at all.

This is a health issue

Nobody could deny that dementia and many other conditions that mean people need care are health issue or that carers are saving the NHS billions. Carers themselves experience physical and mental illness as a result of their care role. Yet much of the dwindling support for carers comes from outside the health system.

The devastating situation for carers is directly related to the current crisis in health and social care. Aside from any considerations of humanity, morality and the duty of the state to look after the most vulnerable people, it is incredibly short-sighted not to provide proper support for the hundreds of  thousands of older people who are providing unpaid care. This is a priceless resource for society which, if it collapses, will bring unimaginable human and economic costs to the NHS as well as the wider society. Conversely, proper investment in support for older carers would bring great rewards. Providing a mandatory assessment which simply quantifies carers’ needs and then telling them that there is no money to meet those needs (the current position for many) is almost worse than no assessment.

The above are some of the reasons why social care should be as much as an issue for SHA as health care and why we need to develop a vision of care that encompasses both. There will always be informal care by people for those they love, but there are some obvious steps that the next Government could take in the health and care arena to improve the situation for carers and for those they care for:

  • immediately reverse the cuts in social care
  • introduce a system of free social care based on agreed definitions of need
  • do away with the artificial distinction between health and social care
  • ensure that information is systematically collected on carers and, separately, older carers, their experiences of caring and its impact on them
  • ensure there is a statutory right to support for carers identified in needs assessments
  • give carers a statutory right to respite from their caring roles
  • provide funding to combat loneliness and isolation among older carers, support for older carers on the death of the person they care for and new opportunities for community involvement following bereavement
  • value professional care workers, who provide support for unpaid carers, and improve their wages and working conditions.
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For older people, beating loneliness isn’t just about where and who they live with

Shailey Minocha, The Open University and Caroline Holland, The Open University

Social isolation and loneliness among older people are public health issues in the UK and have a terrible effect on well-being, physical health – causing depression and mental decline. The health risks associated with social isolation have been compared to the harmful effects of smoking and obesity.

Some new forms of accommodation are trying to give older people more opportunity for social contact in order to combat the empty feelings of loneliness. A new report, launched by the think-tank the International Longevity Centre, surveyed residents in some retirement villages, where people buy apartments with flexible “extra” care on hand. The report argued that village living could promote older people’s quality of life, help to reduce feelings of isolation and loneliness, and increase their sense of control over their own lives.

Housing with extra care services and retirement villages are still a rarity in the UK. They are also not all the same and other research suggests they may not always protect against loneliness.

Vanessa Burholt and her colleagues at Swansea University found that while residents might have more social interactions, loneliness itself wasn’t affected. Residents living in accommodation with extra care didn’t necessarily make new friends and felt their real friends were people they knew from before. Some residents still want to connect with “younger” age groups. Many retirement villages are far from city centres and lack access to public transport. People need support to maintain existing meaningful and long-term friendships during and after the move to extra-care housing and also into care homes.

Housing only part of the problem

Our recent research with people living in ordinary mixed communities – which is where the vast majority of older people live – has identified housing as just one of many factors that affect isolation and loneliness among older people. We discovered many ways of promoting the inclusion of older residents within the neighbourhoods they are familiar with.

Some people develop their own “personal convoy” over time, making connections and cultivating interests to protect themselves against future loneliness. Contact with families is important to feel connected. Some local councils are actively nurturing awareness and the capacity of neighbourhoods and communities to support and look out for older people, such as Bristol with its LinkAge programme. Volunteering within communities (including involving older people as volunteers) can be encouraged – with support from organisations such as Age UK that have experience of training and mentoring volunteers.

Local walking groups, book clubs, local history groups, photography groups, sewing and knitting groups can help. So can using local venues such as parks, garden centres, or cafes as convenient places to meet. For some people, inter-generational activities are helpful, such as school students and older people sharing their skills. One group called HenPower brings older people together to keep hens and combat loneliness, and links up with schools. Others may learn to use the internet from children and share stories related to local history.

‘Older people’ aren’t all the same

Of course the term “older people” covers a lot of ground – from “late middle age to early old age” around 55-65 years, to centenarians. People vary enormously in their capacity and outlook at any age, so it would be over-simplifying just to define people by age groups. There is, however, some sense in thinking about different strategies for different situations connected to the life course and physical capacity: what people are likely to want to be doing – and what they can manage to do.

For example, people still under pension age may lose social contacts because of redundancy, or after a break-up, but not yet be eligible for services for older people such as free bus travel or discounted rail fares. They might want support to get back into the flow through voluntary work, or learning digital skills to enhance their employability.

People in their “third age” (65-79) and “fourth age” (roughly 80-85 and older) might want different services. Retirement villages, lunch clubs and day centres are sometimes perceived as being for the “very old” and may not be attractive for the not-quite-so-old – one reason why housing that comes with extra care is strongly marketed as “lifestyle” housing for active ageing.

Our research has shown that for some people, online social interactions can also be a path to greater social inclusion, with a positive effect on well-being. Wherever someone is living, when increasing frailty or other life changes start to impact on their quality of life, making sure they are “digitally included” could be another way to overcome isolation and loneliness.

Time to get online.
pixinoo / Shutterstock.com

Enhanced digital skills can enable people to benefit from lifelong learning opportunities such as open educational resources and Massive Open Online Courses. However, our research shows the kind of support needed for digital inclusion differs based on a person’s situation. Some older people lack even basic digital skills, but others might be looking to improve their digital skills for employment. Some may be living alone and may not have informal “technical support” from family or friends – or they might have disabilities or age-related impairments to deal with.

So, we suggest an approach to social inclusion that takes into account all the different ways that older people live, as well as where they live.The Conversation

Shailey Minocha is Professor in Learning Technologies and Social Computing at The Open University and Caroline Holland is Senior Research Fellow, Faculty of Health & Social Care at The Open University

The research is neutral and not guided by any political thoughts or interests.

This article was originally published on The Conversation. Read the original article.

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Watching as our parents begin to struggle with the effects of old age can be devastating, and many of us help out as best we can by offering informal care in the home – cooking meals, shopping for groceries, and general housekeeping, for example. In fact, it’s estimated that there are around 3 million children providing care in the home for their elderly parents, without counting those in care homes.

Tea with my old mum in her Care home
For many of us, this is a system that works, but it’s important to remember that situations can and do change. If your parent’s needs change significantly, or your own situation changes, providing care in the home may no longer be a suitable option for either party. So just when should you consider alternative forms of care?

Your Parent’s Changing Needs

The needs of the elderly may change frequently in response to health events, side effects of conditions or medications, or simply as a result of ‘normal’ changes in both the body and mind as we begin to get older, such as reduced mobility, frailty, or mild confusion. Here are some reasons why your parent’s care needs may change, and why you may wish to explore other care options:

  • Degenerative Conditions – Conditions such as dementia, Alzheimer’s disease, and Parkinson’s disease are all degenerative, meaning that the symptoms often get gradually worse.

  • Health Events – Should your parent suffer a minor or major health event such as a fall or stroke, they may become more dependent and require a higher level of everyday care.

  • Confusion – Memory problems are a common complaint amongst the ageing population, and certain medications can also increase confusion. Confusion can increase risk for the elderly.

  • Medications – If your parent has been prescribed essential medications, they may not understand which pills to take – and when. This can increase their care needs, creating changes for you.

Her pills

For the health and safety of an elderly parent, it’s essential that we don’t overlook these changing needs in order to be able to continue providing care in the home. As their children, it’s important that we’re able to recognise these changes and ensure personal and medical needs are being met.

Your Changing Role as Carer

The changing needs of the elderly are not the only reasons to consider looking into alternative care arrangements. If you find that your role as carer is changing beyond what you anticipated, or beyond what you feel you can physically or emotionally handle, it can be very beneficial to explore other options. There’s no need to feel ashamed – sometimes parents require a level of care we’re unable to provide safely. Here are some ways in which your role as carer may change over time:

  • Increased Risks – Should your parent suffer a fall or be affected by mobility issues, you may be required to undertake manual handling as part of your role as carer, which can increase risk.

  • Personal Care – If your parent is unable to perform basic personal care tasks – bathing or using the toilet, for example – you may wish to explore other options if you’re not comfortable.

  • Extended Care – As a parent’s care needs become greater, you may find you’re required for much longer periods of time, which can significantly affect both work and family life.

Looking after her
Never be afraid to admit that your role as carer is changing beyond what you expected, or feel guilty for exploring alternative care options. Studies have found that, when the elderly receive a new form of care after being cared for by someone who is stressed or frustrated, they often demonstrate an improvement in functioning. New care arrangements can be a breath of fresh air – for both of you!

Signs that Suggest Changes Should be Made

Unfortunately, in many cases we may be simply too close to the situation to be able to recognise when our needs, or our parent’s needs, change beyond what we’re physically and emotionally capable of. That’s why it’s important to understand some of the most common signs that suggest that current care arrangements are failing to meet all needs, and be able to identify these signs in our parents.

  • Increased Falls – A higher prevalence of accidents or injury in the home may suggest that the current environment is proving to be too challenging for the elderly to navigate safely.

  • Feelings of Depression – Signs of depression amongst the elderly may be piles of unopened personal mail, poor housekeeping, or a drastic change in appearance such as unbrushed hair.

  • Signs of Risks – If you notice charred burners or burnt pan bottoms in the kitchen, it could suggest that your parent is becoming confused regularly, increasing their risk of injury.

  • Slow Recoveries – If your parent is taking a long time to recover from minor ailments, it could be a sign that they require higher levels of support and extended care to improve health.

  • ADL Performance – Activities of daily living (ADLs) include washing, going to the toilet, dressing, eating, and so on. If a parent is unable to perform these tasks, they may require more care.

If you identify any of these signs, you may wish to begin exploring alternative care home options. However – is this when you would put your parent into a care home? Perhaps not. These signs don’t always mean that a parent needs to move out of their home – in many situations is could simply mean that some changes need to be implemented in order to provide a safer living environment for the elderly.

Alternatives to Care Homes

If you feel that your parent’s needs can successfully be addressed without residential or nursing home care, then there are a number of ways that you can increase the level of support and assistance they receive without having to perform tasks that are beyond what you’re able to provide safely.

  • Home Adaptations – For parents who primarily struggle with mobility, including moving around the home, getting up and down stairs, or using the bathroom, a few minor home adaptations can have a significant impact and encourage independent living. Mobility aids such as stairlifts and walking frames can allow your parent to move freely throughout their home, while grab rails and hoists can assist with bathing and toilet needs. Pick up some brochures and printed literature for relevant companies to see what would suit your family.

  • Care in the Community – Community care can be as formal or as informal as required to meet individual needs. Community care is usually offered by the local authority, age-related charities, or independent providers, with carers undertaking personal care tasks, housekeeping, cooking, minor nursing tasks, and providing companionship at times when you’re unable to be present due to work or family commitments. The number of people receiving local authority care is actually dropping as more people opt for home adaptations.

  • Assisted Living Facilities – Sheltered accommodation for the elderly is considered to be a halfway point between remaining in the community and moving into a care home, and can be an excellent option for many families. Around 10 percent of the elderly in England live in sheltered or retirement housing. Here, residents either own or rent their own apartment and are encouraged to live independently, but have warden support in case of emergencies. There is always a member of staff on hand to call for medical assistance if required.

Residential or Nursing Homes

While the more informal care arrangements such as home adaptations and community care can be very beneficial, it’s important to recognise when these systems aren’t working, and are failing to meet both basic and more specific care needs. If you have a parent whose condition cannot be adequately managed in the community, a residential or care home can be the safest and most suitable option. So which type of care will your parent require? Residential or nursing?

In her wheelchair with the balloons at her Care home

There is a big difference between residential care homes and nursing homes. Residential homes are similar to sheltered accommodation, with the exception that your parent won’t own or rent an apartment – instead, they’ll be ‘residents’ in a large, communal building. Residents will often be encouraged to live as independently as possible, although basic care needs can be provided as required. In cases of ill health or emergencies, residential care homes will contact the relevant GP or emergency service for assistance, and residents may be moved to hospital if they require medical care.

On the other hand, nursing homes will always have at least one registered nurse on duty at all times, and can provide medical assistance and care in line with what nurses are permitted to do under their registration – changing dressings, taking blood, or managing specific conditions such as dementia, for example. Care is provided on a 24 hour basis, and the home may have the ability to treat certain conditions on site without the need to call a GP, or transfer a resident to hospital.

When contemplating sending your elderly parents into a care home, making sure all of the nurses have had the appropriate checks is absolutely essential. www.crbdirect.org.uk can help you through with this.

Choosing the Right Care Home

If you have determined that it’s the right time to transfer your parent into a care facility – either a residential home or a nursing home – don’t be tempted to rush the process. This is a major life event, and it’s vital that you work together with your parent and other family members, to locate the most suitable care home that will meet their needs, provide a safe environment, and encourage healthy living. One of the first tasks you should undertake is to read reports by the Care Quality Commission which oversees care home standards in England. Also take into account the location – you want the home to be easily accessible for visitation – and whether the home can meet medical, religious, and language requirements. You can also check out user reviews on the NHS website – it’s like TripAdvisor for care homes!

The Right Time

Grandad

When would you put your parent into a care home? Every person is different, and there’s no set age at which it’s best for a parent to receive higher levels of care. Some people may continue to live a healthy life in their own home, for example, while others may be struggling to perform day-to-day tasks without a little help and support. What’s important for us as relatives is to be able to recognise when our parents need more than what we can offer, and be prepared to consider alternative care options in order for them to live safely – and happily.

Article supplied by Harold Rigby, health writer with a special interest in issues faced by retired people in care homes.

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According to the Office for National Statistics (ONS) there are currently over 10.8 million people over the age of 65 and this volume is growing – recently published figures have revealed that by 2030 there will be 1 million pensioners who will not have access to care services.

Why community care is important

As they grow older most people would prefer to stay in their own homes and at the heart of their community. Most of this demographic aren’t severely disabled and just need some extra support, they feel that they aren’t eligible for the services of a Care Home, and want to preserve their independence. Local authority budget savings mean that the provision of social care is limited and it is falling to charities and volunteer services to help the elderly preserve their lifestyle in their own homes.

Budget difficulties affect the elderly

A recent article in The Daily Telegraph shows that care in the community has been cut by a third in the last five years and an increasing number of pensioners are affected by the local authority budget deficits. As a result of this, older people are finding it difficult to have access to help with the most basic tasks, including washing and dressing. These are people who don’t have dementia or any other mental health problems; they just need a little extra support to retain their independent lifestyle.

Facts and figures

The government is aware of this problem and has introduced a scheme whereby care costs can be deferred and your house will be assessed as capital, but this only applies to those who have to go into a Care Home. If you have over £23,250 in assets and savings, this doesn’t apply to the value of your house, you will have to contribute to your care costs if you remain in your own home. These costs have led to a massive decline in those who can afford assistance with basic tasks, so that they can remain in their own homes.

The experts join the care debate

Speaking on behalf of the charity Scope, Richard Hawkes, the CEO, said: ‘we now know that community-based care has been hit hard…’ Dr Jose-Luis Fernandez of the London School of Economics (LSE) has suggested that, ‘councils have been quietly tightening their eligibility criteria for care, rationing it to all but those in the most severe need.’

Some solutions

Local religious organisations, volunteer services and charities may be able to help if you need support at home. The Citizen’s Advice Bureau (CAB) publishes lists of local resources for those who need help at home and will also help with your community care assessment. This process can be complex, and varies from region to region so the CAB’s help is invaluable. With the numbers of pensioners in the community set to rise on an annual basis, we need to find an immediate solution to any form of care in the community.

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